The state of the estates

By Dr. N.W. Vidyasagara

The gradual development of health and welfare facilities on estates, could broadly be viewed over three time periods, namely - the colonial era, the period of total state ownership and management and the period of restructuring. The first of these three periods namely the colonial era, witnessed the development of a rudimentary curative oriented health service on estates. The colonial government realised that the health of the plantation worker was economically important and needed to be safeguarded. This resulted in a series of legislative enactments, that required the employment of medical personnel and the establishment of institutional facilities such as hospitals, maternity units and dispensaries, in order to provide basic curative services within the estates. These provisions though stated in legal enactments, in practice were largely optional and linked to incentive schemes involving tax rebates depending upon the services provided.

In the next period of state ownership in the mid-70s the Family Health Bureau of the Ministry of Health was entrusted with the responsibility of implementing an estates family health project, funded by UNFPA, which involved the provision of maternal and child health (MCH) services and other related activities on estates.

Utilizing 10 Government medical officers (estates) who were provided with transport and strategically located in health units (MOH offices) in the plantation areas, and together with the assistance of public health nursing sisters, were able to gradually develop a network of 400 MCH/FP polyclinics in estates, to serve the health needs of mothers and children. The polyclinic initiative, was the first organized preventive health intervention, which had the acceptance of estate management and set the stage for the introduction of more preventive health programmes in the estate health sector.

In the meantime JEDB and SLSPC developed their own Social Development Divisions at central and regional levels and were in a position to be directly responsible for the provision of health and welfare services on estates. To avoid duplication and dual management, the services of the government medical officers (estates) were gradually withdrawn. Other national health programmes, mainly funded by UNICEF were also introduced into the estate sector, such as the expanded programme on immunization (EPI), the control of diarrhoeal diseases programme (CDD), family planning services, nutrition programmes including growth monitoring and the development of a health information system. Hazardous childbirth in line rooms were discouraged, and with funding from donors, the ADB and World Bank, the construction of maternity units on estates was encouraged.

During this period early initiatives also commenced towards crèche development. The Ministry of Health reserved placements for a quota of midwives to be trained for the estate sector, which has contributed immensely to improving the services and the quality of healthcare on estates. These estate midwives, being the equivalent of the Government public health midwife, will in future be the mainstay of healthcare on estates.

The 1980s also witnessed large investments to improve water supply and sanitation supported by donors, the World Bank and UNICEF. All these initiatives contributed much to improvement of health on estates.

The post nationalisation period with assistance from UNFPA, also sought to ensure that all family planning methods were accessible to the estate community either on the estate itself or through government health facilities. With UNICEF advocacy and support, the crèches on estates were improved. 

The impact of health interventions during this period is reflected by a progressive decline in the infant mortality rate from 104 in 1973 to 38.6 per thousand live births in 1990. Though still higher than the national average at that time, the relatively short period in which this was achieved has been remarkable.

The third time period referred to as the period of restructuring, had as its underlying principle, the privatization of the management of estates, with the intention of improving efficiency, achieving higher productivity and generating more profits. 

The operational mana-gement of estates were contracted out by 23 regional plantation companies (RPC), to private sector companies. The privatisation process resulted in a complete change in the management structure for health and welfare established under the JEDB and SLSPC. The social development divisions ceased to function and instead a new limited liability company called the Plantation Housing and Social Welfare Trust (PHSWT) was established under the Companies Act. The health and welfare staff on estates now became employees of the respective plantation companies.

The PHSWT, also referred to as the Trust, became operational in January 1993, with a head office in Colombo and seven regional offices. A 12-member tripartite Board with representation from the Plantation Companies, the Ministries of Finance, Plantation Industry, Health and Housing and the trade Unions, directs the affairs of the Trust. 

Being an independent organization the Trust does not have any direct administrative authority regarding the implementation of health and welfare programmes on estates, unlike the social development divisions of the JEDB and SLSPC. In spite of this limitation, the operational divisions of the Trust drawing their strength from the Board, have been able to establish good liaison and credibility with the plantation companies in maintaining and implementing health. In collaboration with the plantation companies, the Trust seeks to maintain health and welfare services on estates, as well as, expand the scope of activities in keeping with current needs. It is supported in this effort, both financially and technically, by a Plantation Development Support Programme (PDSP), funded by the Dutch and Norwegian Governments.

The health and welfare activities of the Trust, broadly stated would be, monitoring the implementation of national health programmes on estates, promoting the provision of childcare facilities and related services, special programmes of current interest, orientation of management on health and welfare activities and training of health welfare staff, maintaining and utilising a health information system, community mobilisation/participatory activities, water supply, sanitation and estate housing. 

More recently housing and sanitation have received massive funding from both Government and the donor community.

The special programmes of current interest include gender awareness, reduction of alcohol and substance abuse, reduction of soil transmitted nematode infection, adolescent girls' nutrition programme, and prevention of child labour. More recently a Participatory Nutrition Intervention Programme (PNIP) initiated by the Ministry of Plan Implementation and supported by UNICEF has also been introduced on a phased basis. A crèche focus initiative (CFI) emphasizes the pivotal role of the crèche in promoting early childcare and development (ECCD) activities. The promotion of ECCD is strongly advocated and supported by UNICEF.

The impact of the estate sector programmes on health is reflected in some of the health indices for 1997, published in the Health Bulletin of the PHSWT, namely - a crude birth rate of 14.8 per thousand resident population, an infant mortality rate of 24 per thousand live births, a contraceptive prevalence in the use of modern methods of 66.5%, a proportion of 91.6% of estate births occurring in institutions, and a reported incidence of low birth weight on estates of 16.1%.

A recent political decision has required the Ministry of Health/Provincial authorities to take over estate hospitals. Commencing in 1994, 19 hospitals out of 52 have been taken over or are in the process of takeover. 

The problems associated with this are well-known. The absorption of registered (estate) midwives to serve as government midwives has deprived some estates of domiciliary and other preventive health services, till such replacements are available. In today's context whether estates should maintain hospitals does not appear a valid option and most estates have prudently only maintained the maternity sections. On the other hand, whether takeover of estate hospitals by government in order to provide a service at the level of a rural hospital inspite of an extensive national health infrastructure already available seems questionable. It may now be prudent to take stock and reappraise the present strategy before proceeding any further. The National Health Policy 1996 policy statement refers to integration (as opposed to takeover) and provincial health administration might respond more positively by entering into a dialogue with estate management to develop an integrated health service on estates. Today with the estates being grouped in company-wise clusters, a health planning process through discussion between estates and respective Divisional Directors of Health Services/Medical Officers of Health could be initiated. The regional offices of the Trust have been requested to act as a catalyst to further this initiative.

The writer was formerly Director, Family Health Bureau, Ministry of Health and a WHO Regional Adviser (MCH). At present he is a Health Adviser to the Plantation Housing & Social Welfare Trust.

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